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" Cervical cancer incidence increases steeply with deprivation, so efforts must be focused on delivering the programme to those with most to gain from immunisation "

Immunisation - mutual trust in operation

Immunisation programmes reflect one of the most visible examples of the approach to improving and protecting health. Immunisation programmes operate on the basis of trust. An individual places their trust in those who are providing their healthcare that this immunisation is safe and effective whilst others in the community trust that the individual will accept the immunisation offered and thereby reduce the burden of infection in the population. This also means that the few people in the population who are unable to tolerate immunisation can be protected by herd immunity. In general, we all trust that the advice on the potential benefit to society is accurate, based on sound research evidence and balanced against the need to provide a treatment to someone who is not ill. That is why new immunisations are only undertaken when everyone is sure that - on balance - immunisation will benefit those who are eligible.

Cervical cancer and HPV immunisation

Cervical cancer is the second most common cancer in women aged under 35 in the UK. In Scotland, there are about 300 new cases of cervical cancer each year and around 100 women die every year from this disease.

The Human Papilloma Virus (HPV) is the most common cause of this cancer. HPV is a very common virus and it is estimated that eight out of ten people in Scotland will catch it at some time in their lives. HPV is mainly spread by sexual contact. There are over 100 different types of HPV and the HPV vaccine offers protection against two types of HPV that account for 70% of cervical cancers. The vaccine offers very high levels of protection (estimated well above 95% ) against infection with these two high-risk types of HPV in girls who have not previously been infected with the virus.

Routine Human Papilloma Virus (HPV) immunisation programme was implemented from September 2008. This decision was taken by Scottish Government following advice from the UK Joint Committee on Vaccination and Immunisation, the independent expert body that provides advice on vaccines. This programme is an important development in protecting women from cervical cancer. The HPV immunisation programme is for girls aged around 12-13 years and there is a one-off three-year catch up campaign for girls aged 13 to 17 year-old at September 2008.

However, as the vaccine does not protect against some 30% of HPV related cervical cancer, or other causes of the cancer, it remains vital that all women, including those who have been immunised, attend for regular screening. That way it will be possible to spot any precancerous changes in cervical cells and offer effective treatment.

Implementing HPV immunisation in Lothian

In Lothian, some 4,500 girls each year will be offered vaccination as part of the routine HPV immunisation programme. However, if we simply started in a single year and worked forward, there would be some girls who could benefit from the vaccination but who would miss out on the protection that it affords. So, some 18,000 further girls will be offered vaccination between 2008 and 2011 as part of the 'catch up campaign'. This campaign allows rapid immunisation of those girls most likely to benefit. The programme requires administration of three doses of vaccine over a six month period. The routine programme is being delivered in schools and to promote a high uptake five visits to each school are scheduled during the school year. The catch-up campaign will be delivered both in schools and in the community in order to reach those who have left school. Local implementation of the programme has been co-ordinated by a subgroup of the Lothian Immunisation Co-ordinating Group (LICOG).

Staff in NHS Lothian have worked extremely hard to ensure an effective and timely introduction of this complex programme. In particular the staff who run the child health information system (which is being used to keep track of all the immunisations) and staff in NHS pharmacies and school nurses have worked together to deliver the programme. The co-operation and support of Local Authorities and independent schools has also been essential.

An important component of implementation planning has been to develop a Lothian strategy to maximise equity in the delivery of the programme. It is well recognised that cervical cancer incidence increases steeply with deprivation, therefore efforts must be focused on delivering the programme to those with most to gain from immunisation. This is essential in order to ensure that the programme does not widen existing health inequalities.

The programme is being evaluated in Lothian to monitor uptake rates for immunisation and to ensure that the programme is being delivered effectively to those at highest risk of cervical cancer. Data shows that uptake rates for secondary school girls in years S2, S5 and S6 were 93.9, 92.8 and 87.7% for first, second and third doses respectively, which is very positive and shows that an equitable approach can be achieved amongst those at school. In addition, strategies to improve equity, such as working with community partners to deliver the programme to girls out of school, are already having success.

While data for school leavers catch-up and total catch-up cohorts was incomplete at the time of writing, there was good evidence from local staff that the national communications strategy has increased awareness of the immunisation programme among girls.

Key messages

  • Immunisation is one of the ways in which a mutual society protects the health of its population.
  • A new immunisation programme to protect women against the most common forms of cervical cancer caused by HPV has been introduced in Lothian.
  • Initial evaluation suggests that this programme has already achieved over 90% uptake - which is very encouraging and provides an excellent basis on which to build a long-term positive relationship.